Provider Demographics
NPI:1952478596
Name:QUALITY LIFE PSYCHIATRIC & PSYCHOLOGICAL GROUP, INC.
Entity Type:Organization
Organization Name:QUALITY LIFE PSYCHIATRIC & PSYCHOLOGICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:KOTOMORI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:951-684-2627
Mailing Address - Street 1:6529 RIVERSIDE AVE
Mailing Address - Street 2:SUITE 133
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3122
Mailing Address - Country:US
Mailing Address - Phone:951-684-2627
Mailing Address - Fax:951-788-5837
Practice Address - Street 1:6529 RIVERSIDE AVE
Practice Address - Street 2:SUITE 133
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3122
Practice Address - Country:US
Practice Address - Phone:951-684-2627
Practice Address - Fax:951-788-5837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19090103T00000X
CAPSY8086103T00000X
CAPSY 9633103TC0700X
CAMFC 40326106H00000X
CAMFC39054106H00000X
CAMFT 18385106H00000X
CAA603762084P0800X
CAA308272084P0800X
CAA413302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty